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Removal of Ear Wax and Conditions of the Ear

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Removal of Ear Wax and Conditions of the Ear The Royal Victorian Eye & Ear Hospital Nursing Learning Package REMOVAL OF EAR WAX AND CONDITIONS OF THE EAR The Royal Victorian Eye & Ear Hospital REMOVAL OF EAR WAX AND CONDITIONS OF THE EAR LEARNING PACKAGE AIM: This training package is a competency based training program for Outpatient Department Nursing Staff to enhance their ENT knowledge and support the development of an ear care clinic. This training program will develop the nursing staff skill set to ensure that the highest standards of care continue to be delivered at the Royal Victorian Eye and Ear Hospital. OBJECTIVES: After completing this module and with practice the nurse should be able to: 1. Identify the structures of the ear 2. Describe the different areas of the external ear 3. List the functions of the external ear 4. Discuss the function(s) of cerumen 5. Identify the indications for removal of wax 6. Identify common pathological conditions which may be present in the external ear 7. Identify the various ways the ear can be illuminated 8. Perform an accurate examination of the external ear 9. Recognize any abnormalities in the patient’s history &/or examination 10. Document accurately information and findings of examination 11. State the circumstances the patient would be referred to the doctor 12. Competently demonstrate aural suction of the ear and removal of wax 13. Describe any follow-up care that may be required Overview Cerumen is a secretion of glands in the hair bearing region of the ear canal. It is formed as a greasy material but for a number of reasons it may fail to leave the canal, become dry and hard and may accumulate to the point that it is impacted in the depth of the canal. The aim of this course is to demonstrate the techniques of removing wax safely using a wax ring or suction. The prismatic binocular headlight gives such a good view into narrow places that removal of a lump of wax that is obstructing the view into the depth of the canal becomes a simple manoeuvre with a wax ring. With training we believe it should be possible to treat impacted wax without referral to an otology clinic or using the syringe technique. A nasal speculum can open the canal and reveal a boggy mass of cerumen. Removal of wax opens several other clinical possibilities. • The picture above shows the typical appearance of impacted cerumen. There is no space around the mass to pass a wax ring and syringing will be ineffective for the same reason. • We cannot be sure whether this is accumulated keratin associated with a perforated drum until the drum is examined. Until then syringing the ear risks driving infection into the middle ear and causing damage to the inner ear. • Commonly impacted cerumen is putrid. In this case it is not enough to remove the wax in the ear but the otitis externa will need ongoing treatment by an otologist. • Though the patient might notice an improvement in hearing it maybe misleading because the wax impaction is not noticed initially by people with presbycusis (degenerative conductive deafness). Removal of Wax Cerumen is produced to protect the ear by trapping dirt and foreign bodies in the sticky wax and hairs. It should only be removed to allow inspection of the drum or for treating symptoms caused by accumulation or putrefaction. Please read the following article: Clinical practice guideline: Cerumen impaction. Otolaryngology Head and Neck Surgery (2008)139, S1-S21 Roland Peter S. et al It has been produced by a multidiscipline panel. It has defined the presentations that require intervention, and made recommendations about their management. Indications for removal of wax include: • Difficulty in examining the full tympanic membrane • Otitis externa • Wax occlusion of the external ear canal • As part of the workup for conductive hearing loss • Prior to taking the impression for hearing aid fitting • Suspected external ear canal or middle ear cholesteatoma • Suspected external ear canal pathology such as squamous cell carcinoma or eczema • As part of the follow-up to canal wall down mastoidectomy • As part of grommet insertion or middle ear surgery (preoperatively or perioperatively) • Patient request Anatomy The ear canal as part of the temporal bone Anatomy of the tympanic membrane: An long process of incus – sometimes visible through a healthy translucent drum Um Umbo – the end of the malleus handle & the centre of the drum Lr light reflex – antero-inferiorly Lp lateral process of malleus At Attic – also known as pars flaccida Hm – handle of the malleus Illumination Illumination is designed to free your hands and use both eyes. VoroTek headlight gives stereoscpic vision into narrow holes. Adjust the prisms to provide a single image for an object sited about 25cm from the face. When the casing is mounted on a spectacle frame prescription lenses may be fitted. When the lamp is shared amongst clinicians, some of whom use spectacles, it is sensible to use a headlight mounted on a head band. Practice examining right and left ears changing hands for each side Practice using a probe or speculum to hold the tragus out of the view. Practice retrieving a lump of Blue tack from the depth of a pen cap. The otoscope is a common source of illumination. Select the largest speculum that will fit the canal. Hold the otoscope like a pen, not like a hammer. Rehearse using it with either hand Open the tragus and cartilage ring gently, beyond this depth the bony part of the ear canal is tender. Look though the lens and, using the mind's eye, find the posterior wall of the canal. As you insert the speculum further follow the posterior wall to its junction with the posterior rim of the drum Examination of External Ear and Tympanic Membrane Systematically examine the drum 1. Move the speculum so your view pans across the drum as far as the alcove. 2. Identify the malleus and umbo 3. Change the view again and perhaps tip the head away to find the short process 4. If the drum is transparent seek the outline of the incus. 5. Confirm your orientation by locating the light reflex Illustration of the effect the anterior wall of the canal has on the view of the drum Note that the anterior wall of the ear canal often bulges into the line of view and restricts the view of anterior half of the ear drum. Pathology When working within the Wax Clinic it is important that the normal development and resorption of wax is understood. Ear wax contains sebaceous material and the secretions from the ceruminous glands which line the outer one-third of the ear canal. The primary component of ear wax is keratin (derived from dead skin). These secretions combine with desquamated skin and hair to form wax. Wax (cerumen) appears to be partly controlled by circulating catecholamines. It is normal to some cerumen in the ear canal where it provides protection to the skin and also possesses bactericidal activity. Ear canal epithelium migrates outwards, providing a natural cleaning mechanism for desquamated tissue and cerumen. Wax provides protecting to the skin and also possesses bactericidal activity. Attempts to clean the ear usually forces the ear canal contents deeper into the meatus. Wax impaction is therefore a common cause of hearing loss. If water enters the era, the desquamated keratin expands, often trapping fluid deep in the canal. This may cause otits externa unless the plug is removed. Reasons for wax or keratin not passing out of the ear canal include: • dermatitis such as eczema or psoriasis • genetic disorders such as keratosis obturans and ichthyosis • loss of elasticity of the canal skin with aging • a narrow canal such as we see in Downs Syndrome If wax and keratin build up in the ear it may eventually lead to putrefaction of the keratin and infection that may spread back to the middle ear. Surgical closure of the perforation is also effective at preventing keratin accumulation. Patients will not let you remove keratin adhering to a tympanostomy tube. Pulling at a large mass of keratin adherent to the drum risks pulling the ossicle out. Perforation & ventilation tubes. caused by abnormal flow of keratin Swollen, inflamed ear Inflamed, red – otitis external ear canal externa – otitis externa Pathological conditions of the ear Otomycosis The humid, dark conditions in the canal almost inevitably lead to putrefaction of this material by fungae such as Aspergillosis niger (80-90%) and Candida albicans The fungae break through the skin. Bacterial cellulitis is from saprophytic bacteria such as Peudomonas aeruginosa, Proteus and Staphylococcus aureus. The features of cellulitis are • offensive odour and scanty discharge • swelling of the skin • tenderness below the ear canal, and pain moving the pinna • osteomyelitis if there is diabetes present Asp. niger – characterised by black spots. C. albicans – characterised by white discharge. Other pathology found while cleaning the ear, which should be brought to the notice of an otologist include: Diffuse otits externa Also known as “swimmers ear”, but since the cause of the infection is water trapped in the ear canal, bathing or showering may also cause this common infection. When water is trapped in the ear canal, bacteria that normally inhabit the skin and ear canal multiply, causing infection and irritation of the ear canal. If the infection progresses, it may involve the outer ear. It is urgent to reduce the swelling of the canal and clean the depth of the canal and region beside the drum. Persistent discharge from the middle or external ear tends to dry out and create debris that looks like wax. Relapse of infection is commonly from infection hidden by the crust.
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